The December 4 incident at Dunseith Community Nursing Home involved at least five certified nursing assistants who were trying to get Resident #6 ready for supper. The resident, who has anxiety, conduct disorder, and moderate cognitive impairments, was found crying on the floor by the final aide who entered the room.
Staff consistently reported that the resident's bed was wet and she was distressed, yelling, and refusing to cooperate when they tried to move her. During the attempts to transfer her, she ended up naked on the bathroom floor.
Nobody could explain how she got there.
Staff gave conflicting accounts about how the resident ended up on the floor, though several reported she refused to stand or get herself up. A gait belt was applied directly to her bare skin, and staff lifted her with it at least once.
Two nursing assistants were reported to have hollered at the resident, pointing in her face, and insisted that she apologize while she remained on the floor.
The resident was discovered crying by another aide who entered the room later. That aide found scratches on the resident's left arm. No staff could provide a clear explanation for how the scratches occurred.
The final aide refused to leave the resident on the floor and ultimately calmed, cleaned, dressed, and brought her to supper.
The charge nurse was told almost nothing about what happened. She reported being informed only that the resident had a behavior and that a gait belt was used. She was not told about the yelling, the resident being naked on the floor, the number of staff involved, or any injuries.
Federal inspectors found the facility failed to report the incident to administrators and state authorities within required timeframes. Nursing homes must report suspected abuse immediately, but no later than two hours after an allegation is made.
The facility didn't file its incident report until December 10, six days after the incident occurred. State survey officials received the report that same day.
An administrative nurse interviewed by inspectors on December 22 acknowledged that facility staff failed to report the incident in a timely manner. The nurse stated it was not acceptable for staff to holler at or threaten residents.
The resident's medical record shows a behavior event report was filed on December 4 at 5:28 p.m., stating that the resident was yelling and refusing to get up and changed before supper. The report noted that three aides were needed to get her to cooperate and a gait belt was needed to get her toileted.
But the behavior report contained none of the details later documented in the facility's incident report to the state. It made no mention of the resident ending up naked on the bathroom floor, the yelling by staff, or the unexplained scratches on her arm.
The facility's own incident report, filed six days later, painted a much different picture. It documented that several nursing assistants were involved in the incident during attempts to get the resident ready for supper. Multiple staff members went in and out of the room during the prolonged encounter.
The report stated that during attempts to move the resident, she ended up naked on the bathroom floor with conflicting accounts about how she got there. Staff applied a gait belt directly to her bare skin and lifted her with it.
The incident report confirmed that staff hollered at the resident, pointing in their faces, and demanded she apologize while she remained on the floor. It noted that one aide found her crying and discovered scratches on her left arm that no one could explain.
Federal regulations require nursing homes to immediately report suspected abuse, neglect, or theft to the administrator and proper authorities. The failure to report incidents promptly can result in continued abuse, fear, anxiety, and psychosocial harm to residents.
Inspectors found that staff consistently noted yelling toward the resident, difficulty during the transfer, the resident's distress, and that full details were not reported to the charge nurse at the time of the incident.
The resident has a documented history of anxiety and conduct disorder, along with moderate cognitive impairments and delusions according to her most recent assessment. These conditions can make residents particularly vulnerable to the psychological impact of aggressive or demeaning treatment by staff.
The December 4 incident began when staff attempted to get the resident ready for supper. Her bed was wet, and she was distressed and refusing to cooperate with staff attempts to change and move her.
What started as a routine care situation escalated into an incident involving multiple staff members, with the resident ending up naked and injured on a bathroom floor while staff yelled at her and demanded apologies.
The aide who ultimately resolved the situation found the resident crying on the floor and refused to leave her there. That aide calmed the resident, cleaned and dressed her, and brought her to supper.
But the charge nurse, who should have been immediately notified of the incident, was told only that the resident had exhibited behavior problems and that a gait belt was used. The nurse received no information about the yelling, the resident's nakedness, the number of staff involved, or the unexplained injuries.
The facility's delayed reporting meant that state authorities didn't learn of the incident until six days later, preventing immediate investigation and intervention that could have protected the resident from further harm.
Federal inspectors cited the facility for failing to ensure incidents of abuse are reported within required timeframes, noting that such failures may result in continued abuse, fear, anxiety, and psychosocial harm to vulnerable residents.
The administrative nurse's acknowledgment that the delayed reporting was unacceptable and that staff should not holler at or threaten residents came more than two weeks after the incident occurred.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dunseith Com Nursing Home from 2025-12-23 including all violations, facility responses, and corrective action plans.